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Cirrhosis

From Mediwikis

CT Scan of a very cirrhotic liver- note the irregular border
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Following chronic damage, collagen is deposited in the liver, due to activation of hepatic stellate cells into hepatic myofibroblasts, blocking blood flow through the liver.

Causes

Common- ABC

  • Alcohol
  • B (Hepatitis B)
  • C (Hepatitis C)
  • NAFLD

Rare- ABCD

  • Autoimmune - PBC, AIH, PSC
  • Biliary obstruction - biliary atresia, CF
  • Copper in Wilson's disease and other metabolic disoders (haemochromatosis, a-1AT deficiency)
  • Drugs - methotrexate, amiodarone, isoniazid

Diagnosis

  • Biopsy is gold standard, but not always needed
  • Deranged LFTs - raised transaminases and raised g-GT if active alcoholic; hypoalbuminaemia in advanced cirrhosis
  • Raised PTT
  • Hyponatraemia – due to raised ADH and aldosterone
  • FBC: Thrombocytopaenia – due to splenomegaly; macrocytosis - alcohol abuse
  • Viral screen, ferritin and transferrin, autoantibody screen, a-1AT, ceruloplasmin - for causes
  • USS/MRI/CT can also be used, looking at the liver, as well as spleen.

Presentation

  • Spider naevae
  • Leuconychia
  • Palmar erythema
  • Dupytrens contracture
  • Gynaecomastia
  • Hypogonadism
  • Organomegaly
  • Ascites
  • Jaundice
  • Portal hypertension

Decompensation

  • Jaundice
  • Encephalopathy
  • Ascites
  • Asterixis

Complications

  • Portal hypertension - porto-systemic shunting which may cause acute variceal bleeding
  • Ascites - a transudate. Take a sample of ascetic fluid to identify cause and exclude SBP (see below. Treated with dietary salt and fluid restriction and diuretics. If resistant or intractable - treat with therapeutic paracentesis.
  • Spontaneous bacterial Peritonitis – peritonitis without any obvious source of infection. Occurs in patients with portal hypertension. Hepatic encephalopathy, abdo pain, and ileus are common symptoms. PMN count >250cells/mm3 in ascitic fluid. First line treatment is tazocin
  • Hepatic encephalopathy - precipitated by build up of ammonia, benzodiazepines or cytokines. Treated by managing precipitating factors and regular lactulose
  • Hepatorenal syndrome – rapid deterioration of renal function in absence of other idenfiable cause in individuals with cirrhosis/liver failure due to arterial vasodilation and decreased cardiac output causing regional arterial vasoconstriction.
  • Hepatopulmonary syndrome – SOB and low p02 due to vasodilation (and fall in BP) in lungs of patient with cirrhosis/liver failure. Worse when sitting upright.